Gaps exposed in tracking of C. difficile cases

Editor's note: This is the second in a three-day series examining Clostridium difficile, a potentially lethal infection gaining a foothold in San Joaquin County and across the country.

Deborah Schoch, CHCF Center for Health Reporting

Editor's note: This is the second in a three-day series examining Clostridium difficile, a potentially lethal infection gaining a foothold in San Joaquin County and across the country.

A surge of local residents suffering severe diarrhea and abdominal pain began arriving last October at San Joaquin General Hospital in French Camp, puzzling the emergency room staff that examined them.

Tests revealed that they were afflicted with Clostridium difficile, a serious infection spread by tiny spores in health care settings that is best known for sickening the elderly.

Yet this outbreak didn't fit the mold.

"There were young men and women. There were some children. I'd never seen anything like it," said registered nurse Susan Mitchell, infection control coordinator at the 196-bed county-run hospital that serves many of San Joaquin County's poor and uninsured.

Stranger still, most of them were infected with C. difficile in the community, not in a hospital or nursing home, she said. "That surprised us. We hadn't seen that before."

In all, the hospital reported 27 C. difficile cases in the last three months of 2011, with all but one of them contracted outside the facility. That compares with the 21 cases the hospital reported in the 12 months ending March in 2011, say hospital officials, who refer to the fall 2011 phenomenon as an outbreak.

What happened at San Joaquin General reveals a gaping hole in how the public health care system tracks a gastrointestinal ailment that has quickly grown to become one of the most deadly types of infections in the United States. It now kills 14,000 to 30,000 people nationally, according to federal estimates.

Yet in California and in most other states, it is not a publicly reportable disease. Although doctors are mandated to notify local health departments about 84 other illnesses - rabies, pertussis and cholera among them - they do not have to report C. difficile, even at a time when a virulent new strain is spreading.

The state requires that only hospitals -not nursing homes, surgical centers or doctors' offices - report cases of the infection. Those reports go to the state Department of Public Health, which, since 2010, has issued public reports annually about infections that sicken people during hospitalization.

The problem is, only one-quarter of C. difficile's victims nationwide initially show symptoms as hospital patients. The other 75 percent of cases surface among people in other settings, such as nursing home residents and those recently treated in doctors' offices, according to the U.S. Centers for Disease Control and Prevention.

In fact, experts are growing alarmed at new evidence of community cases - people who are infected outside of hospitals or nursing homes.

Not only is C. difficile spreading outside of health care centers, but those cases may never be accounted for in the current reporting system.

Catching the Stockton area outbreak of autumn 2011 was an anomaly, in part because many of the sickened residents lacked health insurance and turned to a public hospital where infection experts spread the word.

If those residents were insured, they might have sought care from private doctors, who are not mandated to report individual cases.

No one ordered San Joaquin General to report its C. difficile cases to Dr. Karen Furst, San Joaquin County's public health officer.

But Furst got a call anyway, from Mitchell at San Joaquin General, describing the large number of infected patients arriving for emergency treatment.

"I was glad she called us," Furst said. "Otherwise, it's not a condition that we monitor for, or that skilled nursing facilities would necessarily think of calling us about."

Many of those diagnosed at San Joaquin General had delayed care so long that they became seriously ill, officials there said.

"People were thinking, 'It's just abdominal pain.' They weren't really quick to come in. By the time they did, it was a very advanced disease," said Carla Bomben, the hospital's deputy director for standards and compliance. All 26 people who showed up infected were hospitalized, but none died.

Just how they were sickened may never be known. Furst said that C. difficile remains an infection most associated with health care and close contact with an infected person.

"People are not going to get it from going to the grocery store, or going to the gym and working out," she said.

Mitchell also contacted Jon Rosenberg, who heads the program on healthcare-associated infections at the state Department of Public Health. Rosenberg told her that the secret is early identification.

So the hospital worked in tandem with other area hospitals and nursing homes to identify patients at risk and test them promptly.

"We made a decision that we were going to put this thing down," Mitchell said.

Soon, state officials are expected to release their 2011 annual report on C. difficile cases at all general acute care hospitals in the state. That report will provide a sharper picture of the impact of last autumn's outbreak in the Stockton area.

But it will not solve the riddle of why that outbreak occurred or how many people became ill.

That gap in information is why some patient advocates believe that C. difficile should be publicly reportable in California, and why a law requiring the reporting of some cases of Methicillin-resistant Staphylococcus Aureus, or MRSA, another virulent health-care acquired infection, should be strengthened.

The agency that has "the power to make it reportable is the Department of Public Health," said Carole Moss of Gavilan Hills in Riverside County, who helped spearhead the state's 2008 hospital reporting law after her 15-year-old son died of MRSA.

State law currently says that health providers should report "outbreaks of any disease" to local health officers, but critics say the language is too vague to have clout.

The state Department of Public Health is responsible for reportable diseases, as well as infectious diseases and health care quality issues.

Department staff responded to The Record's questions for this series with emails.

Asked if the department might make C. difficile reportable, a spokesman, wrote in an email that the public health department "consults with the California Conference of Local Health Officers on a regular basis to add diseases of public health significance to the reportable list. When a decision is made to add a disease to the list, an announcement is made to healthcare providers."

The president of the California Conference is Dr. Wilma Wooten, health officer for San Diego County. She said that although the panel advises the state, its committee on reportable diseases is chaired by a state health department representative. She does not recall the panel discussing making C. difficile reportable.

Diseases are reportable "because of the burden that they cause to the health care system," Wooten said. "If there are adverse complications or death, we want to know about it."

To consider adding C. difficile, health officials would have to consider trends and its public impact, she said, adding, "Anyone can bring an issue to our attention."

Several infection control experts said they are not convinced that it's time to list C. difficile, but that it might be worth a review.

"Discussing it would be great. Hammering out the details would be extensive," said Paula Newman, infection control nurse at St. Joseph's Medical Center in Stockton and president of the regional chapter of the Association for Professionals in Infection Control and Epidemiology.

The outbreak tapered off in January at San Joaquin General. Today, the hospital is treating significantly fewer people for C. difficile, and they are not as sickly when they arrive. Bomben credits the teamwork among hospitals and nursing homes.

"It was remarkable, in a good way," she said.

The CHCF Center for Health Reporting (www.centerforhealthreporting.org) is an independent news organization. It is based at the University of Southern California's Annenberg School for Communication & Journalism and funded by the nonprofit California HealthCare Foundation.